Advanced Practice: Neutropenic Fever in the ED
What’s all the fuss about neutropenia?
- The neutrophil count bottoms out (the "nadir") days 5-10 after last chemotherapy treatment.
- The risk of infection is dependent on the degree and duration of neutropenia
- Important Cutoffs:
- Neutropenia: absolute neutrophil count < 1000/mm3
- Severe Neutropenia: absolute neutrophil count < 500/mm3
- Profound Neutropenia: absolute neutrophil count < 100/mm3
- Signs and symptoms are often minimal due to the diminished inflammatory response
- Mortality rates as high as 5-20%
Where to Start:
- Do not take a rectal temperature in a potentially neutropenic patient
- Check: urinalysis, urine culture, chest xray, blood cultures
- Assess any lines for source of infection and draw blood culture from the site as well
- If a source is found, therapy can be guided
- Treatment is more difficult without a known source
- Be on high alert for new abdominal pain: this may be typhilitis (also known as neutropenic enterocolitis), a potentially catastrophic complication of neutropenia
- Initiate gram negative coverage (typically cefepime 2g IV, aztreonam or meropenem if severe allergy to cephalosporins)
- Evidence supports empiric antibiotics when the patient has severe neutropenia even if a specific organism is not found
- There is little evidence for antibiotics when the patient is not neutropenic
- Vancomycin only required if there is concern for catheter infections (or a history of MRSA in the patient)
1 Lyman. How We Treat Febrile Neutropenia in Patients Receiving Cancer Chemotherapy. J Oncol Pract. 2010 May; 6(3): 149-152.
2 Denshaw-Burke. Neutropenic Fever Empiric Therapy. Medscape. February 11, 2016. https://emedicine.medscape.com/article/2012185-overview
3 Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.